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an* was in his 20s when he started gaming in the mid-1990s. A long-time interest in building PCs had developed into an initially healthy interest in first-person shooters like Counter Strike and Team Fortress, which he'd play at weekends and when he came home from work.

It was the online element of these games, he says, that really changed his relationship to gaming, and what started as a hobby quickly took over his life.

"I was working, I had a family, so it was a slow progression," he says. "But then - and it sounds really weird when I say it now - I started thinking about it at work, and the first thing I'd do when I got home was start drinking and start up the internet and game."

Video games are enjoyed by millions of people around the world without any harmful effects whatsoever. Most players will never have to worry about it becoming a problem. But for a small number of people, what starts out as a fun hobby becomes a debilitating habit. Though behavioural addictions like gaming, gambling or sex can be less physically debilitating than similar addictions to drugs or alcohol, their impact can be no less severe. Ian recalls setting up a computer in his dining room, where he'd play until midnight every night - the time his dial-up connection finished - often using drugs and alcohol to allow him to keep gaming.

When I got home on a Friday night, I would sit at the computer and I wouldn't leave until Sunday night

"Every night up until that time I would play," he says. "When I got home on a Friday night, I would sit at the computer and I wouldn't leave until Sunday night. I would use amphetamines to stay awake and just game continuously, and I would only leave the computer to go to the toilet. It just consumed my life."

Ian's addiction to gaming got so bad that, eventually, he ended up losing his family and job. "I just wasn't there - I was there in body in the house, but I wasn't looking after my children," he says. "I wasn't there for them."

Though often sensationalised by a tabloid press keen to put the boot into the latest gaming fad, gaming addiction is a real and growing problem. The World Health Organization has listed and defined gaming disorder as a condition warranting further research in the 11th edition of International Classification of Diseases (ICD-11), citing an increase in the development of treatment programmes across the world - something that has already started happening in the UK.

Primrose Lodge treatment centre in Guildford, UK. Photograph: Primrose Lodge

One centre providing such treatment is Primrose Lodge, an addiction centre set in quiet, leafy countryside just outside Guildford. Staff there say they have seen a recent increase in patients seeking help for gaming addiction.

"It's really happened over the last 12 months or so," senior therapist Matthew Preece tells me.

Preece runs one-to-one and group sessions with patients at the centre, with a focus on techniques taken from dialectical behavioural therapy (DBT).

"The key element of DBT is that it's based on mindfulness practice," Preece explains. "We're talking about relapse prevention here - the person being able to maintain their emotional regulation, being able to recognise emotions, and challenging existing thoughts and behaviours."

Other techniques include exercises to help change physical sensations and manage compulsive behaviours - something that could be as simple as a focused, structured breathing exercise, or plunging your hands into cold water - and processes to help people with confrontation, dialogue and communication.

Spotting the difference between obsession and addiction can be hard, Preece says, especially when it comes to gaming. Someone with a gambling addiction, he suggests, may be more easily able to tell that they had a problem, because they might be losing tens of thousands of pounds. When someone has a gaming addiction, however, "the consequences are more subtle". Millions of people enthusiastically play games - and despite media scrutiny of popular games like Fortnite or Call of Duty, the vast majority of them are not addicted in any real sense.

It's when gaming "starts to be of detriment to other areas of someone's life - their work, relationship, their self-care," that it becomes a problem, Preece says. "If someone tries to cut down, and they find they can't control that, or if they start to be secretive or dishonest about their behaviour - they're kind of the main things to look out for."

We still don't know exactly what the basis for gaming addiction is, explains Pete Etchells, lecturer in biological psychology at Bath Spa University. "There's a lot of debate and argument in the research literature about this," he says. "There's a lot of uncertainty around whether it's best to frame it as something akin to a substance abuse disorder, or whether it's best looked at in terms of something like an impulse control behaviour."

"There's also the wider question of whether gaming disorder is an actual disorder in and of itself, or whether it masks other underlying disorders. So, say you have a person with signs of clinical depression who uses gaming as a coping mechanism - it might look as though they have a gaming addiction. But actually, it's the underlying depression that probably needs to be treated."

The problem is not purely psychological, either, adding another element to the debate.

"All games need a hook," Adam Procter, programme leader of the Games Design and Art BA course at the University of Southampton, says. Designers - somewhat obviously - focus on mechanisms that draw players in, he explains, something that "often involves a level of replayability".

This could be something as simple as a leaderboard - where you can compare your gameplay with friends - or as varied as purchasable in-game content that allows you to enhance your character or make changes to the game experiences. This could come in the form of a loot box - where you don't know what kind of content you might end up with - or in the form of specific purchases.

Research confirms this: one pilot study in 2013 found that specific features of games were associated with "problematic behaviours associated with addiction-like experiences". Games providing increasing rewards - earning points or finding rare items, for example - or games with a "high social component", where players were likely to play and share tips and strategies with others, had a significant association with addictive behaviour. These kinds of mechanisms are built into games - something Procter compares to Sean Parker's statement that his team at Facebook constantly asked themselves: "How do we consume as much of your time and conscious attention as possible?".

This kind of functionality was pivotal in Ian's addiction - he specifies purchasable skins and character upgrades and leaderboards as part of his obsession - and has been frequently cited as problematic elsewhere. Loot boxes in particular, which work much like gambling, have been described as " predatory", with the Belgian Gaming Commission even going so far as banning them.

So, with a growing awareness of gaming disorder, do designers have a responsibility to prevent or curtail addiction?

Game makers are deliberately tapping into an addictive process

Preece thinks so. "There needs to be a responsibility," he says. "They're deliberately tapping into an addictive process ... so yes, I would like to see more responsibility around that."

Procter says that game makers "should be aware that the product they're making will have an impact on players", and that "there will always be a responsibility for makers to consider their impact on the world".

"As designers, we should recognise this rise in games addiction, and have an open discussion about industry wide safeguards along with parent education," he says.

Ian, now in recovery from his addiction and rebuilding his life, hopes that the ICD listing of the disorder will raise awareness of the issue - and educate people on something that they currently don't understand.

"People look down on it. They don't think of it as serious," he says. "But it's the same as gambling, alcohol, drugs, or any other addiction. It can be very dangerous, very harmful, and very destructive."

* Name has been changed

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'It consumed my life': inside a gaming addiction treatment centre

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an* was in his 20s when he started gaming in the mid-1990s. A long-time interest in building PCs had developed into an initially healthy interest in first-person shooters like Counter Strike and Team Fortress, which he'd play at weekends and when he came home from work.

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To call gambling a "game of chance" evokes fun, random luck and a sense of collective engagement. These playful connotations may be part of why almost 80 percent of American adults gamble at some point in their lifetime. When I ask my psychology students why they think people gamble, the most frequent suggestions are for pleasure, money or the thrill.

While these might be reasons why people gamble initially, psychologists don't definitely know why, for some, gambling stops being an enjoyable diversion and becomes compulsive. What keeps people playing even when it stops being fun? Why stick with games people know are designed for them to lose? Are some people just more unlucky than the rest of us, or simply worse at calculating the odds?

As an addiction researcher for the past 15 years, I look to the brain to understand the hooks that make gambling so compelling. I've found that many are intentionally hidden in how the games are designed. And these hooks work on casual casino-goers just as well as they do on problem gamblers.

Uncertainty as its own reward in the brain

One of the hallmarks of gambling is its uncertainty - whether it's the size of a jackpot or the probability of winning at all. And reward uncertainty plays a crucial role in gambling's attraction.

Dopamine, the neurotransmitter the brain releases during enjoyable activities such as eating, sex and drugs, is also released during situations where the reward is uncertain. In fact dopamine release increases particularly during the moments leading up to a potential reward. This anticipation effect might explain why dopamine release parallels an individual's levels of gambling "high" and the severity of his or her gambling addiction. It likely also plays a role in reinforcing the risk-taking behavior seen in gambling.

Studies have shown that the release of dopamine during gambling occurs in brain areas similar to those activated by taking drugs of abuse. In fact, similar to drugs, repeated exposure to gambling and uncertainty produces lasting changes in the human brain. These reward pathways, similar to those seen in individuals suffering from drug addiction, become hypersensitive. Animal studies suggest that these brain changes due to uncertainty can even enhance gamblers' cravings and desire for addictive drugs.

Repeated exposure to gambling and uncertainty can even change how you respond to losing. Counterintuitively, in individuals with a gambling problem, losing money comes to trigger the rewarding release of dopamine almost to the same degree that winning does. As a result, in problem gamblers, losing sets off the urge to keep playing, rather than the disappointment that might prompt you to walk away, a phenomenon known as chasing losses.

Lights and sounds egg you on

But gambling is more than just winning and losing. It can be a whole immersive environment with an array of flashing lights and sounds. This is particularly true in a busy casino, but even a game or gambling app on a smartphone includes plenty of audio and visual frills to capture your attention.

But are they just frills? Studies suggest that these lights and sounds become more attractive and capable of triggering urges to play when they are paired with reward uncertainty. In particular, win-associated cues - such as jingles that vary in length and size as a function of jackpot size - both increase excitement and lead gamblers to overestimate how often they are winning. Crucially, they can also keep you gambling longer and encourage you to play faster.

Feeling like a winner while you're losing

Since games of chance are set up so the house always has an advantage, a gambler wins infrequently at best. You might only rarely experience the lights and sounds that come along with hitting a true jackpot. However, the gaming industry may have devised a way to overcome that issue.

Over the last few decades, casinos and game manufacturers significantly upgraded slot machines, retiring the old mechanical arms and reels in favor of electronic versions known as electronic gaming machines. These new computerized games and online slots come with more attractive colorful lights and a variety of sounds. They also possess more reels, ushering in a new era of multi-line video slot machines.

Having multiple lines enables players to place a bunch of bets per spin, often up to 20 or more. Although each individual bet can be small, many players place the maximum number of bets on each spin. This strategy means a player can win on some lines while losing on others, netting less than the original wager. Even when you "win," you don't come out ahead, a phenomenon known as " losses disguised as wins." Yet each win, even when it is a loss disguised as a win, comes with the lights and sounds of victory.

The result is that these multi-line slot machines produce more enjoyment and are highly preferred by players. Crucially, they tend to make gamblers overestimate how often they're truly winning. The dramatic increase in the frequency of wins, whether real or fabricated, produces more arousal and activation of reward pathways in the brain, possibly accelerating the rate at which brain changes occur. Multi-line slots also seem to promote the development of "dark flow," a trance-like state in which players get wholly absorbed in the game, sometimes for hours on end.

Almost: Near-miss effect and chasing your losses

The rise of electronic gambling machines also means that rather than being constrained by the physical arrangement of different possible outcomes on each reel, possible outcomes are programmed onto a set of virtual reels. Gaming designers can therefore stack the deck to make certain events occur more frequently than others.

This includes near-misses, where one of the reels stops just short of lining up for a jackpot. These near-miss almost-wins recruit areas of the brain that usually respond to wins, and increase one's desire to play more, especially in problem gamblers.

This phenomenon is not confined to slot machines and casinos. Near-misses play an integral part in the addictive potential of smartphone games like the very popular "Candy Crush."

Near-misses are more arousing than losses - despite being more frustrating and significantly less pleasant than missing by a longshot. But crucially, almost winning triggers a more substantial urge to play than even winning itself. Near-misses seem to be highly motivating and increase player commitment to a game, resulting in individuals playing longer than they intended. The size of the dopamine response to a near-miss in fact correlates with the severity of an individual's gambling addiction.

Gambling and its games

When you engage in recreational gambling, you are not simply playing against the odds, but also battling an enemy trained in the art of deceit and subterfuge. Games of chance have a vested interest in hooking players for longer and letting them eventually walk away with the impression they did better than chance, fostering a false impression of skill.

For many people, these carefully designed outcomes enhance the satisfaction they get from gambling. It may remain easy for them to simply walk away when the chips run out.

But gambling isn't only a lighthearted promise of a good time and a possible jackpot. Up to 2 percent of the U.S. population are problem gamblers, suffering from what's recently been reclassified as gambling disorder.

It stands out as one of the few addictions that doesn't involve consumption of a substance, such as a drug. Like other forms of addiction, gambling disorder is a solitary and isolating experience. It's tied to growing anxiety, and problem gamblers are at greater risk of suicide.

For these more susceptible individuals, the game designers' hooks start to seem more sinister. A solution to life's problems always feels just one spin away.

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Designed to deceive: How gambling distorts reality and hooks your brain

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To call gambling a "game of chance" evokes fun, random luck and a sense of collective engagement. These playful connotations may be part of why almost 80 percent of American adults gamble at some point in their lifetime. When I ask my psychology students why they think people gamble, the most frequent suggestions are for pleasure, money or the thrill.

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On June 18th 2018, the International Classification of Diseases 11 (ICD-11) was published by the World Health Organisation. This diagnostic manual, currently only available to stakeholders for adaptation, has legitimised 'Gaming Disorder' as a mental health disorder. On the same day, a video was published on the World Health Organisation's YouTube channel providing context for the controversial decision:

The specific attention paid to Gaming Disorder in the video is a result of a prolonged period of controversy surrounding the diagnosis. I originally wrote this article before the official legitimisation of Gaming Disorder. Now that it is legitimised, I have made a few changes to it.

The purpose of this article is to educate people on what Gaming Disorder is and why it was such a contested inclusion in the ICD-11. This will include what academics have to say about it, some controversies on the diagnosis, and what the future of Gaming Disorder may look like.

There will be a summary at the bottom for those who do not wish to read everything. Please enjoy!

Context

Gaming Disorder is a mental health disorder included in the World Health Organisation's ICD-11, a diagnostic manual of physical and mental health disorders. The diagnostic criteria includes:

...a pattern of persistent or recurrent gaming behaviour ('digital gaming' or 'video-gaming'), which may be online (i.e., over the internet) or offline, manifested by: 1) impaired control over gaming (e.g., onset, frequency, intensity, duration, termination, context); 2) increasing priority given to gaming to the extent that gaming takes precedence over other life interests and daily activities; and 3) continuation or escalation of gaming despite the occurrence of negative consequences...

Please note that the ICD-11's Gaming Disorder is different from the DSM-V's 'Internet Gaming Disorder' (IGD). IGD is included in the DSM-V as a 'condition for further study', meaning that they would like researchers to explore the validity of the criteria before legitimising it as a diagnosable mental health disorder. There is no trial period for Gaming Disorder: once the ICD-11 is published with Gaming Disorder, it can be diagnosed.

Gaming Disorder was added to the ICD-11's beta draft list in approximately September 2016 and was available to view as a frozen beta draft release in October 2016. Although the publication of the ICD-11 has experienced delays since 2012, the WHO are aiming for a publication date in the second half of 2018. This was indeed achieved with a release date of June 18th 2018.

The Research

This is the part of 'The Psychology of...' where I bombard you with research, tell you what the statistics mean, tell you what the overall conclusion is and hopefully leave you feeling happy and educated.

Except...there is no research.

With the introduction of Gaming Disorder in September 2016 and a publication date of 2018, there has been no time to conduct research on the proposed definition and criteria for Gaming Disorder. As a researcher myself, allow me to demonstrate the work that goes into conducting and publishing research.

As for how long this process takes, it is impossible to define. Each of these steps can take months, perhaps years if data is collected longitudinally. It is no surprise to me that no research has been published on Gaming Disorder yet considering how long the research process takes.

However, that does not mean that academics are staying silent on the matter. Several open letters to the WHO have been published following the beta draft inclusion, each with their own important arguments for why Gaming Disorder should and shouldn't be included. As I am passionate about bringing academia to the public, I am going to summarise these open letters so gamers can understand the current academic climate surrounding Gaming Disorder.

I would like to state that I am beginning with the 'against' side of the inclusion of Gaming Disorder as the first article I will be summarising is discussed in each subsequent article. I am doing this for organisation and clarity, not for bias.

Gaming Disorder - Against

The first open letter to come out against the inclusion of Gaming Disorder in the ICD-11 is 'Scholars' open debate paper on the World Health Organization ICD-11 Gaming Disorder Proposal' (Aarseth et al., 2016). This paper is authored/signed by a whopping 26 academics spanning 24 universities/research institutes.

This letter is supported by a number of academics that work on exploring the positive and negative aspects of technology use, with four of the authors writing their doctoral thesis on addictive patterns of gaming. The authors are transparent in wanting some form of official recognition for pathological gaming, but believe that the current move by the WHO is far too premature.

The first issue cited is a lack of consensus on what Gaming Disorder should look like due to a lack of research on the topic. This is particularly true of studies conducted with clinical samples of pathological game playing due to low sample sizes.

The second issue cited is the overreliance on gambling criteria to try to develop a criteria for Gaming Disorder. If an addiction is behavioural rather than biological, this is less straightforward than simply saying someone is addicted to a substance and experiences withdrawal without it. As a result, the authors feel that the criteria for Gaming Disorder is underdeveloped and too similar to criteria for gambling addiction.

One example that is provided is thinking about video games during your leisure time. Being excited to leave work and hunt monsters with your friends is not inherently similar to being excited to leave work and spend hours in a dark room gambling away your paycheque on slot machines. This, combined with the fact that there is no research which validates the criteria for Gaming Disorder, means we do not know if the criteria is specific or valid enough to represent what addictive gaming looks like.

The third issue cited is the fact that addictive gaming seems to often be accompanied with other mental health disorders such as depression or anxiety disorders (Kardefelt-Winther, 2014); this is called 'comorbidity'. It is argued that the suggested criteria for Gaming Disorder may not be robust enough to detect whether someone is playing games for reasons such as a distraction from depressive symptoms or gaining social contact that their undiagnosed Social Anxiety Disorder prevents them from doing. I have seen this practice referred to as 'Bed Syndrome'. If someone is depressed and spends all day in bed, you do not diagnose them with Bed Syndrome, you look at why they spend all day in bed. There is a fear that if a person's gaming is focused on and not the person themselves, this will lead to inadequate mental health treatment.

Continuing on with fears of inadequate mental health treatment, Professor Andrew Przybylski, Senior Research Fellow at Oxford Internet Institute, spoke about the premature pathologising of gaming. While this interview is in regards to Internet Gaming Disorder, the implications are the same for Gaming Disorder which will be legitimised as a mental health disorder before IGD.

In the mental health system, a diagnosis is a vehicle which helps steer you towards a correct and appropriate treatment path. The WHO has not specified the treatment plan for Gaming Disorder, but pre-existing treatment plans have Professor Przybylski concerned:

Detox camps are very worrying to me as a scientist because they have no scientific basis, many of those who run them have financial conflicts of interest when they comment in the press, and there have been a number of deaths at these facilities.

- Przybylski, 2017

Research conducted by Przybylski and colleagues (Weinstein, Przybylski, & Murayama, 2017) supports the idea that pathological gaming may be a method of distracting from other life difficulties rather than being the difficulty itself. In a study of those who believed they met the criteria for Internet Gaming Disorder, there was a significant relationship between the IGD criteria and feeling incompetent, powerless and feeling like they do not belong. After a six-month follow-up period, those who felt more competent, choiceful and felt a sense of belonging no longer met the criteria for IGD and had better self-reported health.

Finally, Przybylski fears that the pathologising of a popular hobby may lead to even further stretching of a mental health system that is already overstretched in many countries.

To summarise, the arguments against the inclusion of Gaming Disorder revolve around its lack of research, its lack of validity assessment, its lack of comorbidity assessment, its lack of treatment outline and its overreliance on conventional gambling criteria.

Gaming Disorder - For

The first paper that I will be looking at which supports the inclusion of Gaming Disorder in the ICD-11 is 'Inclusion of gaming disorder in the diagnostic classifications and promotions of public health response' (Shadloo et al., 2017).

The argument is made that researchers are not trying to demonise regular behaviours like playing video games, and that this inclusion will not impact your everyday gamer. Instead, Gaming Disorder is made to help those who need it.

When articles started coming out about recognising Gaming Disorder as a mental health disorder, I saw many comments from people boasting that they would sit at home all day and play video games to get 'disability bux'. However, this paper makes the situation sound a lot less amusing:

This argument really makes it sound like a vicious cycle. Because Gaming Disorder is not legitimate, countries where mental health access is dictated by insurance cannot treat people who may be addicted. Because Gaming Disorder is not legitimate, a treatment protocol cannot be developed. Because a treatment protocol is not developed, scary 'detox camps' funded by external agencies remain as scary and prevalent as ever.

In a nutshell, the authors of this paper want Gaming Disorder to be legitimised so: 1) people can get access to mental health treatment through their insurance, and 2) development can begin on healthy, safe treatment options away from scary and dangerous detox camps. However, one thing this paper does believe is that the WHO has done a poor job in validating the diagnostic criteria.

In 'ICD-11 Gaming Disorder: Needed and just in time or dangerous and much too early?' (van den Brink, 2017), the author empathises with the tricky situation that the WHO is in. The DSM-V is able to enjoy the luxury of researching Internet Gaming Disorder without any backlash due to IGD being included in the 'conditions for further study' category. However, the WHO does not have this category. Instead, they must decide whether to prioritise validating and researching their diagnostic criteria or giving people access to mental health care through their insurance.

'Problematic gaming exists and is an example of disordered gaming' (Griffiths et al., 2017) argues that the act of publishing a diagnostic criteria for Gaming Disorder provides researchers with a clear goal to work on and assess. This could be viewed as somewhat of a vicious cycle. Aarseth et al. (2016) argue that there is no consensus in video game addiction research, but Griffiths argues that a consensus can be worked towards if there is "...an officially recognized and unifying diagnostic framework", something which Gaming Disorder provides. Similarly to Shadloo et al., Griffiths believes Gaming Disorder will help the very small minority rather than stigmatising the majority.

To summarise, the inclusion of Gaming Disorder will allow for people to receive treatment for video game addiction through health insurance, will work towards a healthy treatment plan free from 'detox camps', and will give researchers a goal to work on and validate.

Gaming Disorder - Miscellaneous

I will quickly discuss one paper that does not take a strong stance one way or the other, but makes a good point about Gaming Disorder.

'The relationship between gaming disorder and addiction requires a behavioral analysis' (James & Tunney, 2017) argues that 'gaming' is simply too reductionist and that greater attention needs to be paid towards the addictive aspects of games such as mobile games. In my article on the psychology of loot boxes and microtransactions, I pointed out how certain game genres are more addictive and can encourage microtransactions more than other genres. As this point has a research basis to it, I believe it deserves more exploration.

Controversy

During my research on Gaming Disorder, I came across quite an interesting and perhaps controversial series of press statements regarding Gaming Disorder from WHO advisors.

In the summer of 2017, Polygon published an article discussing Gaming Disorder and what it could mean for gamers. Dr Geoffrey Reed, a member of the WHO advisory board, had this to say to Polygon:

However, Dr. Vladimir Poznyak, coordinator of the Management of Substance Abuse department of Mental Health and Substance Abuse for the WHO, had something completely different to say:

I don't really know what to make of this. At best, this is miscommunication within the WHO and one very dissatisfied member of the advisory board. At worst, it is something more sinister.

The Future

ICD-11 and Gaming Disorder are here. We've talked about the pros, we've talked about the cons, now we need to talk about the future.

In my clarification piece on Gaming Disorder, I briefly outlined the future for Gaming Disorder:

Furthermore, a hypothetical publication date of June 2018 does not mean that clinicians will immediately begin using ICD classifications. Each country has to make a decision on what classification systems to use and when to transition to these classification systems. For example, despite the ICD-10's release date of 1992, America did not transition to ICD-10 codes from ICD-9 codes until October 1st, 2015.

However, more information on this process comes from the admin of DX Revision Watch, a site which catalogues changes made to the ICD-11 and DSM-V. This information comes courtesy of a Twitter thread which I will put in prose for ease of reading:

ICD Revision's Dr Chris Chute told me, in Feb '17, it will likely be five or six years before member states have evaluated the new edition and are prepared for transition. [It] will take [the] USA longer as they need to develop a clinical modification and also develop an ICD-11-PCS. Member states will evaluate, prepare their health systems and transition to the new edition at their own pace.

There will be no WHO mandated date for adoption of the new edition, though they will not support ICD-10 indefinitely. So for some years, post release, WHO will be collecting and aggregating data recorded using both ICD-10 and ICD-11. NHS UK has yet to project a date by which ICD-11 is planned to be implemented.

Dr Chris Chute (chair, MSAC), Feb 2017: "...What is produced say in 2018 will continue to evolve, ICD11 is designed for graceful evolution. It may differ in substantial ways by the time the first country implements it, say 5-6 years from now from what is put forth in 2018..."

- DX Revision Watch, 2018

To summarise, it will be a number of years before the ICD-11 is used and member countries are placed under no time restriction for moving on to the ICD-11. Before moving on, each country will assess the proposed criteria and suggest changes based on evidence. As such, what is published on Gaming Disorder in 2018 is likely to change as more countries assess the ICD-11 within clinical samples.

Thank you very much for reading and please have a nice day.

Summary

Gaming Disorder was included as a mental health disorder in the ICD-11 in June 2018. The criteria includes frequent video gaming, giving priority to video gaming over other activities and repeated gaming despite negative consequences.

Due to the length of time required to conduct and publish research, no study exists which assesses the validity of the diagnostic criteria. While we await research findings, academics have been publishing letters and papers discussing the pros and cons of the inclusion.

The cons of including Gaming Disorder include: a lack of research evidence, a lack of validation for the Gaming Disorder criteria, no clear treatment path, no consensus among researchers about what Gaming Disorder should look like, criteria which is unjustly similar to gambling addiction, and a fear of overburdening the mental health system with vague diagnostic criteria.

The pros of including Gaming Disorder include: giving addicted people access to mental health care through health insurance, working towards a healthy and safe treatment option away from dangerous 'detox camps', and working towards a consensus on Gaming Disorder.

Some academics would also like to see 'gaming' expanded on to recognise that different genres can be more addictive than others (such as mobile games).

There was some controversy in 2017 as a member of the WHO advisory board stated that the WHO was under political pressure to include Gaming Disorder in the ICD-11. This statement was denied by another WHO member.

When Gaming Disorder is included in the ICD-11, it is likely that changes will be made to the criteria after global research and assessment.

References

Aarseth, E., Bean, A. M., Boonen, H., Colder Carras, M., Coulson, M., Das, D., ... & Haagsma, M. C. (2016). Scholars' open debate paper on the World Health Organization ICD-11 Gaming Disorder proposal. Journal of Behavioral Addictions, 6(3), 267-270.

Griffiths, M. D., Kuss, D. J., Lopez-Fernandez, O., & Pontes, H. M. (2017). Problematic gaming exists and is an example of disordered gaming: Commentary on: Scholars' open debate paper on the World Health Organization ICD-11 Gaming Disorder proposal (Aarseth et al.). Journal of Behavioral Addictions, 6(3), 296-301.

James, R. J., & Tunney, R. J. (2017). The relationship between gaming disorder and addiction requires a behavioral analysis: Commentary on: Scholars' open debate paper on the World Health Organization ICD-11 Gaming Disorder proposal (Aarseth et al.). Journal of Behavioral Addictions, 6(3), 306-309.

Kardefelt-Winther, D. (2014). A conceptual and methodological critique of internet addiction research: Towards a model of compensatory internet use. Computers in Human Behavior, 31, 351-354.

Shadloo, B., Farnam, R., Amin-Esmaeili, M., Hamzehzadeh, M., Rafiemanesh, H., Jobehdar, M. M., ... & Rahimi-Movaghar, A. (2017). Inclusion of gaming disorder in the diagnostic classifications and promotion of public health response: Commentary to the "Scholars' open debate paper on the World Health Organization ICD-11 Gaming Disorder proposal": A perspective from Iran. Journal of Behavioral Addictions, 6(3), 310-312.

van den Brink, W. (2017). ICD-11 Gaming Disorder: Needed and just in time or dangerous and much too early? Commentary on: Scholars' open debate paper on the World Health Organization ICD-11 Gaming Disorder proposal (Aarseth et al.). Journal of Behavioral Addictions, 6(3), 290-292.

Weinstein, N., Przybylski, A. K., & Murayama, K. (2017). A prospective study of the motivational and health dynamics of Internet Gaming Disorder. PeerJ, 5, e3838.

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The Psychology of Gaming Disorder - Psychology and Video Games

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On June 18th 2018, the International Classification of Diseases 11 (ICD-11) was published by the World Health Organisation. This diagnostic manual, currently only available to stakeholders for adaptation, has legitimised 'Gaming Disorder' as a mental health disorder.

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Hamish loves playing the game Fortnite. Does his brain show signs of addiction?

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The Brief Addiction Science Information Source (BASIS)

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Some people who gamble do so regularly, while others might have episodic patterns of gambling and non-gambling. Binge gambling is another type of gambling, where people gamble in irregular patterns but gamble a lot when they do. Are these patterns related to gambling harms? This week, reviews a study by Sean Cowlishaw and colleagues that explores how different patterns of gambling behaviors relate to harms.
What is the research question?
Do people who binge gamble experience different gambling-related harms than those who gamble continuously, regularly, and irregularly?
What did the researchers do?
The researchers recruited 214 patients from a medical provider in London, England. They classified participants into four categories based on their patterns of gambling: ²

1. Continuous (i.e., near daily gambling without breaks);

2. Regular episodic (i.e., alternation between gambling and non-gambling);

3. Irregular episodic (i.e., alternation between gambling and non-gambling);

4. Binge (i.e., loss of control over gambling during an irregular episodic gambling episode, beginning suddenly after a period of abstinence. Does not experience pre-occupation with gambling during abstinence).

Participants also responded to questions about anxiety, depression, and gambling-related problems. ³ ⁴ ⁵ The researchers used logistic regressions to evaluate whether people who experienced binge, episodic, or continuous gambling also experienced differences in gambling-related harms.
What did they find?
Regular episodic and continuous gamblers had similar profiles. However, compared to continuous gamblers, irregular episodic gamblers were 7% less likely to report high anxiety, 9% less likely to experience gambling-related problems, and 49% less likely to experience any mental health related problems. (See Figure 1.) Binge gamblers were also 9% less likely than continuous gamblers to experience gambling-related problems.

Figure 1. Asterisks indicate statistically significant odds ratios. Click image to enlarge
Why do these findings matter?
People with different patterns of gambling experience different harms. Treatment providers can better support these people if they can learn to distinguish between the different problems these individuals might face. Gambling frequency patterns might be an important marker of mental health consequences.
Every study has limitations. What were the limitations in this study?
To assess patterns of binge gambling, the authors created a new screening tool ² that has not yet undergone validity testing. Validity testing helps ensure that a new tool measures what the researchers think it does. In addition, researchers have recognized that sometimes gambling behaviors might be better explained by a manic episode or medications (e.g., dopamine agonists for Parkinson's Disease), rather than Gambling Disorder.
For more information:
If you think that you or anyone you know might be experiencing substance use or gambling-related problems, you can find help resources on the BASIS addiction resources page.

-- Pat Williams
What do you think? Please use the comment link below to provide feedback on this article.
¹ Patients were eligible to participate in the study if they were referred to the clinic for the first time.

² Participants responded to questions about patterns of gambling behavior on the Binge Gambling Screening Tool (e.g., Did you start to gamble suddenly after a period of abstinence?"). This tool was newly designed for implementation within the current study.

³Participants responded to questions about anxiety on the GAD-7 (e.g., feeling nervous or on the edge in the past two weeks)

⁴Participants responded to questions about depression on the PHQ (e.g., little interest or pleasure in doing things)

⁵Participants responded to questions about gambling-related problems on the PGSI (e.g., gambling in larger amounts to get the same feeling of excitement)

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The WAGER, Vol. 23(8) - Binge gambling and gambling-related harms

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Some people who gamble do so regularly, while others might have episodic patterns of gambling and non-gambling. Binge gambling is another type of gambling, where people gamble in irregular patterns but gamble a lot when they do.

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GamCare - Founder of the National Gambling Helpline

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The National Gambling Helpline provides free support for anyone affected by gambling harms in Great Britain.

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Breakeven: free counselling help for problem gambling

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Breakeven, a GamCare counselling partner, offers free counselling to anyone affected by problem gambling. Breakeven bases in Sussex, Kent, Essex, Suffolk and Lincolnshire, UK.

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Help for problem gamblers

There's evidence that gambling can be successfully treated in the same way as other addictions. Cognitive behavioural therapy usually has the best results.

Treatment and support groups are available for people who want to stop gambling:

GamCare GamCare offers free information, support and counselling for problem gamblers in the UK.

It runs the National Gambling Helpline (0808 8020 133) and also offers face-to-face counselling.

The National Centre for Behavioural Addictions includes the National Problem Gambling Clinic (including the Young Persons' Problem Gambling Clinic) and the National Centre for Gaming Disorders.

If you live in England or Wales, are aged 16 or over and have complex problems related to gambling, you can refer yourself to the National Problem Gambling Clinic. See if you meet the criteria for this service.

If you live in England or Wales, are aged 13 or over and have complex problems related to gaming, you can refer yourself to the National Centre for Gaming Disorders.

NHS Northern Gambling Service provides specialist addiction therapy in the north of England, including the north Midlands. Find out about referrals and contacting the Northern Gambling Service.

Gordon Moody Association The Gordon Moody Association offers residential courses for men and women who have problems with gambling - email help@gordonmoody.org.uk or call 01384 241292 to find out more.

It also runs the Gambling Therapy website, which offers online support to problem gamblers and their friends and family.

Gamblers Anonymous UK Gamblers Anonymous UK runs local support groups that use the same 12-step approach to recovery from addiction as Alcoholics Anonymous. There are also GamAnon support groups for friends and family.

If you're affected by someone's gambling

If you're having problems because of another person's gambling, it's best to be honest with them about it. They need to know how their behaviour is affecting you.

Support is also available to people who are worried about someone else's gambling:

GamCare Gamcare offers support and information for partners, friends and family of people who gamble compulsively.

GamAnon
Local support groups for anyone affected by someone else's gambling problem - find your nearest group.

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There's evidence that gambling can be successfully treated in the same way as other addictions. Cognitive behavioural therapy usually has the best results. Treatment and support groups are available for people who want to stop gambling: GamCare GamCare offers free information, support and counselling for problem gamblers in the UK.

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This leaflet is for:

anyone who is worried about their gambling

the family, partner and friends of anyone whose gambling has become a problem.

In this leaflet you can find out about:

Is problem gambling common?

Is my gambling a problem?

How can someone lose control of their gambling?

Potential harms of problem gambling

Steps to reduce gambling - helping yourself

What help can I get?

How to get help

Living with a problem gambler - advice for family, partners and friends

Further reading.

What is problem gambling?

This is defined as gambling that disrupts or damages personal, family or recreational pursuits.

How common is problem gambling?

Many of us like to place the odd bet or play the lottery - but it's only a problem for about 9 people in every 1000. However, a further 70 people out of every 1000 gamble at risky levels that can become a problem in the future.

Who is most likely to get this problem?

Across the world it seems to be common:

In men - but this might just be because women gamble less than men.

In teenagers and young adults - but problems of this sort can start at any age. Children as young as 7 may find it difficult to control the amount of time they spend on computer games. Older people may have too much time on their hands.

If someone else in your family - particularly one of your parents - is a problem gambler. This may be partly due to genes but can be learnt - by seeing a parent gamble or being taught to gamble by them.

In people who work in casinos, betting shops or amusement arcades.

In certain types of gambling:

Internet gambling

Video poker

Dice games

Playing sports for money

High-risk stocks

Roulette

If you drink heavily or use illegal drugs.

If you have depression, anxiety orbipolar disorder (manic depression).

Is it a problem for me?

Answer 'yes' or'no' to each of these 10 questions:

Do I spend a lot of time thinking about gambling?

Am I spending larger amounts of money on my gambling?

Have I tried to cut down or stop gambling - but not been able to?

Do I get restless or irritable if I try to cut down my gambling?

Do I gamble to escape from life's difficulties or to cheer myself up?

Do I carry on playing after losing money - to try and win it back?

Have I lied to other people about how much time or money I spend gambling ?

Have I ever stolen money to fund my gambling?

Has my gambling affected my relationships or my job?

Do I get other people to lend me money when I have lost?

If you have answered 'yes'

Just once - May be a problem - this one thing may be enough of a problem to need help.

Three times - Problem gambling - your gambling probably feels out of control - think about getting help.

Five or more times - Pathological gambling - your gambling is probably affecting every part of your life - get help.

How do you lose control of your gambling?

You may gamble:

to forget about responsibilities

to feel better when you feel depressed or sad

to fill your time when bored (especially if not working)

when you drink or use drugs

when you get angry with others - or yourself.

Or, you may have:

started gambling early - some people start as young as 7 or 8

never been able to control your gambling

one or both parents who are problem gamblers.

Potential harms associated with problem gambling

Problem gamblers are more likely than other people to experience the following harms:

Financial harms: overdue utility bills; borrowing from family friends and loan sharks; debts; pawning or selling possessions; eviction or repossession; defaults; committing illegal acts like fraud, theft, embezzlement to finance gambling; bankruptcy; etc...

Family harms: preoccupied with gambling so normal family life becomes difficult; increased arguments over money and debts; emotional and physical abuse, neglect and violence towards spouse/partner and/or children; relationship problems and separation/divorce.

Health harms: low self-esteem; stress-related disorders; anxious, worried or mood swings; poor sleep and appetite; substance misuse; depression, suicidal ideas and attempts; etc...

School/college/work harms: poor school, college or work performance; increased absenteeism; expulsion or dismissal.

Should I stop gambling or try to control it?

The first thing is to decide to get help - you can then work out whether you are ready to stop or just want to control your gambling better. Many people just want to control their gambling, but then decide to stop completely.

Steps to reduce gambling - helping yourself

Although there is no substitute for professional help, here are some simple and practical measures to reduce gambling:
1. Limit the amount of money you spend gambling

Set a limit from the start on how much you are willing to spend on gambling in a session or in a week. Stick to it!

Leave credit/cash cards at home when you go out to gamble.

If you use a betting account, ask them to place a limit on it - say £50 - this works for online casinos too!

On pay day, aim to pay all your priority debts first (mortgage, rent, council tax, food, etc...)

2. Reduce the amount of time and days that you gamble

Set yourself a limit on how many times a week you will gamble (e.g. twice a week) - be specific and name the days.

Avoid those "I'll just have a quick go" scenarios.

You can set your alarm on your watch or phone to remind you - even your PC will have a calendar reminder alert you can use.

3. Don't view gambling as a way of making money

Always remember that you are buying entertainment.

Always be prepared to lose - if you win, know that it will happen by chance.

Never spend your savings or investments on gambling.

Ask friends and family not to lend you money if you ask them.

4. Spend time doing other activities

Spend more time with family or friends.

Take up a new hobby or interest or revisit one that you enjoyed before gambling took over.

Join a social group or organise events with friends who don't gamble.

Talk to other about your worries or concerns rather than 'bottling' them up.

Where can I get help?

All of the following provide free support to help you cut down or stop gambling:

NHS: The CNWL National Problem Gambling Clinic in London has doctors, nurses, therapists, psychologists, debt counsellors and family therapists with special experience in helping problem gamblers.

Gamcare - runs the national HelpLine and its online equivalent, the NetLine, to offer help and support for people with a gambling problem, their family and friends. GamCare also provides face-to-face online counselling in many parts of the UK.

The Gordon Moody Association - a charity which provides treatment and housing for problem gamblers.

The 12 step meetings of Gamblers Anonymous.

Gamanon: groups for relatives of problem gamblers.

What sort of help is there?

Cognitive Behavioural Therapy (CBT)

Research has shown that CBT can:

reduce the number of days a person gambles

reduce the amount of money they lose

help a gambler to stay away from gambling once they have stopped.

How does CBT work? If you are a problem gambler, you will think differently from other people about your betting. You will tend to believe that:

you are more likely to win than you would expect by chance;

in a game with random numbers, like roulette, certain numbers are more likely to come up than others;

winning twice in a row means that you are on a 'winning streak' - so you bet larger and larger sums;

you are more likely to win at a game of chance if you are familiar with it;

certain rituals can bring you luck;

having lost, you can somehow win back your losses by gambling more.

CBT is given in around 10 one-hour sessions. The sessions focus on these ways of thinking, but also on how you feel and behave when you want to bet or when you are gambling. CBT helps you to work out more helpful ways of thinking and behaving. A diary helps you to keep track of your improvement. In the months following treatment, follow-up CBT sessions in a group seem to help people stay away from gambling longer.

How does CBT compare with other treatments? We don't know yet - there have not been enough large studies to be clear about this.

12 Step Programmes

This is an approach which assumes that a dependence on drink or gambling is a disease, and that the best people to support you are those who have had similar experiences. Regular meetings are held in which people can share the problems they have had and the ways in which they have overcome them. They also have a 'buddy' system, where each member has another member whom they can contact if they feel that they are about to drink or gamble again. The 12 Step Fellowship, Gamblers Anonymous, offers meetings throughout the UK and many problem gamblers find these meetings helpful. You may also need practical help:

managing your debts

dealing with family problems

treat other psychological/psychiatric problems, e.g. depression.

Medication

No medication is licensed for the treatment of problem gambling in the UK, but antidepressants can be prescribed to help with low mood.

What if I don't get help?

About a third of problem gamblers will recover on their own, without treatment, and about 2 in 3 will continue to have problems, which tend to get worse.

How to get help and when

Don't wait until life does not seem worth living. If you get help, you will feel better and avoid many problems with your life and health.

You can refer yourself by calling or emailing the contacts below:
Living with a problem gambler

Being married to or a partner of a problem gambler - or being their parent or child - is hard and can be distressing.

Your loved one will probably have tried to hide the size of the problem from you, while they have at the same time borrowed or stolen to pay off debts.

If, with the help of the 10 questions above, you can see that gambling is a problem for someone in your family, it's best to be honest with him or her about it. They need to know about the pain and trouble they are causing other people and that help is there for them.

If your gambling relative doesn't take any notice, you can get support for yourself from one of the services listed at the end of the leaflet. There are groups and individual sessions to support family members.

References

American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders 5 Washington, DC.

Black D et al (2003) Quality of life and family history in pathological gambling. Journal of Nervous and Mental Disease, 191, 124-126.

Blaszczynsky AP et al (1991) A comparison of relapsed and non-relapsed abstinent pathological gamblers following behavioural treatment. British Journal of Addiction, 86, 1485-1489.

Griffiths MD (1990) The acquisition, development, and maintenance of fruit machine gambling in adolescents. Journal of Gambling Studies, 6, 193-204.

Ladouceur R et al (2002) Understanding and treating pathological gambling. New York, Wiley.

Lesieur HR, Rosenthal MD (1991) Pathological gambling: A review of the literature (prepared by the American Psychiatric Association Task Force on DSM-IV Committee on disorders of impulse control not elsewhere classified). J Gambling Studies 7:5-40.

Petry N (2005) Pathological Gambling. American Psychological Association.

Shaffer HJ, Bilt JV and Hall MN (1999) Gambling, drinking, smoking and other health risk activities among casino employees. American Journal of Industrial Medicine, 36, 365-378.

Wohl MJA et al (2002) The effects of near wins and near losses on self-perceived personal luck and subsequent gambling behaviour. Journal of Experimental Social Psychology, 39, 184-191.

Wardle H, Moody A, Spence S, Orford J, Volberg R, Jotangia D, et al (2010) British Gambling Prevalence Survey. National Centre for Social Research. London: The Stationery Office.

Further reading

Orford J (2010). An unsafe bet?: The dangerous rise of gambling and the debate we should be having. Wiley-Blackwell, UK.

Orford J (2003). Gambling and problem gambling in Britain. Brunner - Routledge

Bowden-Jones H, Clark L (2011). Pathological gambling: A neurobiological and clinical update. British Journal of Psychiatry, 199: 87-89.

George S, Copello A (2011). Treatment provision for Britain's problem gamblers: present gaps and future opportunities. Advances in Psychiatric Treatment, 17:318-322

This leaflet was produced by the RCPsych Public Education Editorial Board.

Series Editor: Dr Philip Timms

Original Authors:

1. Dr Henrietta Bowden - Jones, National Problem Gambling Clinic & Imperial College, London

2. Dr Sanju George, Birmingham and Solihull Mental Health NHS Foundation Trust

Expert review: Faculty of Addictions' Users and Carers Group

Illustration by Lo Cole: www.locole.co.uk

This leaflet reflects the best available evidence available at the time of writing.

© February 2014. Due for review: February 2016. Royal College of Psychiatrists. This leaflet may be downloaded, printed out, photocopied and distributed free of charge as long as the RCPsych is properly credited and no profit is gained from its use. Permission to reproduce it in any other way must be obtained from permissions@rcpsych.ac.uk. The College does not allow reposting of its leaflets on other sites, but allows them to be linked to directly.

For a catalogue of public education materials or copies of our leaflets contact: Leaflets Department, The Royal College of Psychiatrists, 21 Prescot Street, London E1 8BB, Telephone: 020 3701 2552.

Charity registration number (England and Wales) 228636 and in Scotland SC038369.

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This leaflet is for: anyone who is worried about their gambling the family, partner and friends of anyone whose gambling has become a problem. In this leaflet you can find out about: Is problem gambling common? Is my gambling a problem? How can someone lose control of their gambling?

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The National Gambling Support Network, formerly known as, 'The National Gambling Treatment Service', is a group of organisations across Great Britain who provide free, confidential and personalised support for anyone who's experiencing problems from gambling, as well as those affected by someone else's gambling.
If you're worried about your own or someone else's gambling, this service is totally free to access, 24 hours a day, 7 days a week.

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GambleAware®: Gambling Help & Gambling Addiction

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Free, confidential help and support to anyone who's worried about their - or someone else's - gambling. If gambling's on your mind, we're here to help.

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Coronavirus disease (COVID-19) notice

With the easing of restrictions, Groups across the country are beginning to resume their physical meetings in line with the government's guidelines. Many online meetings are still taking place. A list of online meetings can be found here. If you have any questions, please use the relevant phone number on the contact us page contact.

Gamblers Anonymous
Gamblers Anonymous is a fellowship of men and women who share their experience, strength and hope with each other so that they may solve their common problem and help others do the same.

This site offers various aids for the compulsive gambler including a forum, a chat room, literature and most importantly a meeting finder.

Meetings are the core of Gamblers Anonymous and we have meetings every day of the week throughout England, Wales and Ulster.
Links to other Gamblers Anonymous sites: -
Gamblers Anonymous Scotland: - https://gascotland.org/

Gamblers Anonymous Ireland: - https://www.gamblersanonymous.ie/

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This site offers various help for the compulsive gambler including a Forum, Chat Room, Literature and of course most importantly a meeting finder

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There is an increasing understanding that gambling is a public health issue, yet insufficient mainstream effort is being used to address gambling related harms. While many people gamble and experience no adverse consequences, many others experience harms from their gambling.

Gambling is not illegal. It generates considerable tax revenue for UK governments, provides employment, creates innovation within business communities, provides benefits to other leisure sectors, and gives pleasure and enjoyment to some participants. However, there are also considerable societal costs, often unseen and unacknowledged, arising from the harms associated with it, particularly in vulnerable and deprived communities. Importantly many children are exposed to gambling as part of everyday lives, not least on via social media.

In Britain, there are more than 340,000 adult problem gamblers and a further 1.7 million experiencing some harms . But the harms that arise from gambling are far broader than medical-based criteria for problem gambling. Partners, families, and communities also suffer the serious consequences.

The good news is that policy makers, regulators, and the broader public health community are increasingly recognising that gambling-related harms need to be better understood and measured.

For example, the Department of Health and Social Care (DHSC), working with Public Health England (PHE), is supporting an evidence-based review of the impacts of gambling-related harms on health and wellbeing. In Wales the Chief Medical Officer majored on gambling in his annual report and in Scotland there is growing concern about the lack of appropriate provision to prevent gambling-related harms. The National Institute for Health and Care Excellence (NICE) is discussing development of treatment guidance and the Gambling Commission is consulting on the next iteration of its strategy, putting a public health approach at its core.

And there have been some significant signals of the general acceptance that more needs to be done to reduce gambling related harm. When the responsible minister, Tracey Crouch, resigned it precipitated a climb-down by the Treasury on the pace of introducing the £2 limit for Fixed Odds Betting Terminals. Parliamentarians in both Houses raised their concerns about the more general issues of the growth of online gambling and increasing numbers of children involved in gaming and gambling.

The proliferation of advertising around sporting events, particularly on television and especially before the 9pm watershed, is increasingly being seen as leading to normalization of betting behaviors and has led to a proposal for a voluntary ban around televised football matches by the Remote Gambling Association (RGA), which includes a deal to stop adverts during live sports broadcasts.

Children and young people are growing up in a vastly different world from their parents. Their world is dominated by technology and being almost constantly connected to the world via the internet. It cannot be right that 1 in 8 11 to 16 year olds are following gambling companies on social media. There are those who say that this amounts to grooming children, and that the constant stream of gambling-related promotion activity represents abuse.

The recent report by the Gambling Commission describes this changing world, one in which social media and online gambling are on the increase, yet poorly understood. The comorbidity with mental health problems and the impact of debt increase the importance for better understanding of betting, gambling, and how to prevent its incipient harms, not least the higher rates of suicide amongst problem gamblers. At the same time there is a lack of education - for parents, policy makers, and providers of health services. And there is a significant treatment gap. Currently the NHS does not commission any specialised clinics and those that exist are funded through the charity GambleAware, which although independent is funded by the industry.

GambleAware is the primary commissioner of specialised problem gambling treatment services in Britain. Last year around 8,700 people were treated in those services , less than 3% of the estimated population of problem gamblers-a gap that the state needs to help bridge with both funding and leadership. Part of the problem is that gambling falls under the remit of the department for culture, media, and sport, not the health department. It is only recently that NHSE and PHE have engaged in discussion about problem gamblin g and a brief, but important, reference is made to gambling in the new NHS 10 Year Plan. So a good start is being made. But there is much more to do.
Sian Griffiths, Emeritus Professor, Chinese University of Hong Kong. Visiting Professor, Institute of Global Health Innovation, Imperial College London. Declaration of interest: Associate Board member, Public Health England. Trustee, GambleAware. Trustee, Royal Society of Public Health. Marc W. Etches is Chief Executive of GambleAware. Declaration of interest: GambleAware is wholly independent of the gambling industry but does receive funding from gambling businesses via an arrangement prescribed by the regulator, the Gambling Commission. It is a condition of holding a gambling licence in Britain that an annual financial donation must be made to one or more organisations for the purposes of research, education, and treatment in relation to reducing gambling-related harms. Full details are available via www.begambleaware.org.

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Gambling: an unaddressed public health challenge, especially for children - The BMJ

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There is an increasing understanding that gambling is a public health issue, yet insufficient mainstream effort is being used to address gambling related harms. While many people gamble and experience no adverse consequences, many others experience harms from their gambling. Gambling is not illegal.

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Understanding and responding to gambling-related harm: A brief guide for professionals

This free e-learning course has been developed with charity GambleAware. This resource will provide useful guidance to those providing brief interventions to address risks and harms related to problematic gambling.

It also contains an optional topic for organisational leaders wishing to set up and implement the processes necessary to support workers to provide intervention. The programme can be completed in two hours.

The programme is aimed at professionals who do not specialise in the treatment of gambling problems and may be most suitable to those working in social and criminal justice settings. Example roles include social workers, employment advisers, GPs, psychologists, probation officers.

The programme covers:

What is a brief intervention?

How to provide a brief intervention

Important considerations and responding to affected others

Requirements at an organisational level (optional topic)

Resources to aid brief intervention

Use the resource

View the e-learning full screen.

Once you have viewed the programme, we would greatly appreciate it if you would take the time to complete a short feedback survey on your e-learning experience. It should take no more than five minutes.

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Understanding and responding to gambling-related harm: A brief guide for professionals

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This free e-learning course has been developed with charity GambleAware. This resource will provide useful guidance to those providing brief interventions to address risks and harms related to problematic gambling. It also contains an optional topic for organisational leaders wishing to set up and implement the processes necessary to support workers to provide intervention.

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Treatment penetration for gambling disorder is currently low - estimated to be at just 1-2% [1].

The Treatment Needs & Gap Analysis research indicates that there is strong demand for treatment and support amongst people suffering gambling harm. Evidence also suggests that if there was more awareness of the support that is available, it would motivate people to seek treatment [2].

The National Gambling Treatment Service campaign seeks to promote self-referrals amongst those who are high risk of, or are currently experiencing, gambling disorder by directing them to the National Gambling Helpline and online support at BeGambleAware.org.

GambleAware launched a new campaign during February and March 2020 to raise awareness of the treatment available through the National Gambling Treatment Service. The campaign ran on digital media, radio, pubs, motor way service stations, in GP surgeries and health publications. The campaign aims to drive the audience to call the National Gambling Helpline or visit the National Gambling Treatment Service landing page - begambleaware.org/NGTS.

The National Gambling Treatment Service

The National Gambling Treatment Service works with, and alongside, the National Health Service. It is free at the point of delivery, provides telephone, on-line and face-to-face treatment for individuals and groups, across Great Britain. Self-referrals through the 24/7 National Gambling Helpline are the main route for accessing the treatment, which is provided by a network of NHS trusts and voluntary sector organisations.

The campaign draws upon the insight that people with gambling problems feel disconnected from their family and friends and is based on promoting confidence that treatment is easy to access and will help them overcome their struggles with gambling.

The campaign is also seeking to raise awareness of gambling treatment among primary care staff. This is so that GPs and practice nurses can signpost people to the National Gambling Helpline if they identify a patient has a gambling problem.

The National Gambling Treatment Service is part of an overarching strategy to help more people at risk of, or suffering from, gambling disorder. Additional investment is also directed at increasing the capacity of treatment services, expanding the number of locations where treatment is delivered, and offering new options for accessing treatment.

This initiative is part of the collaborative approach which was announced in NHS England's Mental Health Implementation Plan.

The NGTS Campaign

The campaign is based around the sense of "when you're there, but not there". For a person with a gambling problem, whose mind is constantly preoccupied with gambling related anxiety, everyday places become lonely places.

Places of interaction with family and friends become places of isolation. The mind is increasingly preoccupied with urges to bet and worries over bills and debts. The campaign acts as a reminder of the relationships and love they have around them and what they have to gain by quitting. Alongside these reasons to pick up the phone, the campaign seeks to engender a sense of optimism that these benefits can be realised.

A second burst of activity is now running across digital media, radio and press (national & regional) which will run throughout July & August.

[1] GambleAware estimate based on Health Survey number of 'problem gamblers' and GambleAware information on number of people in treatment.
[2] 'Treatment Gap Analysis' research can be found here.

Campaign for: End Users

Campaign for: Healthcare Professionals

Campaign trifold leaflet: Front Page

Campaign trifold leaflet: Back Page

These images are for information only, and are not suitable for printing. If you would like a professional printed copy, please contact info@gambleaware.org.

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National Gambling Treatment Service Campaign | BeGambleAware

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Treatment penetration for gambling disorder is currently low - estimated to be at just 1-2% [1]. The Treatment Needs & Gap Analysis research indicates that there is strong demand for treatment and support amongst people suffering gambling harm. Evidence also suggests that if there was more awareness of the support that is available, it would motivate people to seek treatment [2].

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Skip Content We provide advice, education and high quality innovative therapeutic support to problem gamblers and those affected by gambling, through residential, online and outreach services. Talk to us by text to find out more about the residential programme Do you spend too much money and/or time gambling?

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Gambling is a highly profitable commercial activity with providers that include international corporations and governments.

The past decade has seen unprecedented growth in commercial gambling. The prevalence of problem gambling in different countries across the world was estimated to vary between 0·1% and 5·8% in 2019. Revenue from advertising has increased substantially, driven by gambling in the home and on mobile devices. In 2018-19, the total revenue for the UK gambling industry was £14·3 billion, with £5·6 billion lost by online gamblers in 2018.

Gambling-related harms are the "adverse impacts from gambling on the health and wellbeing of individuals, families, communities and society".,

Gambling has the potential to negatively affect physical health, psychological health, and the social functioning of the people who gamble and others around them. Various terms have been used to describe potentially harmful gambling behaviour, including compulsive gambling, addictive gambling, problem gambling, and pathological gambling.

These terms all refer to a pattern of excessive gambling with impaired control over gambling behaviour, substantial negative consequences deriving from this impaired control, and persistence in excessive gambling despite these negative consequences.

Previous reviews have shown that education and prevention initiatives could succeed in increasing knowledge and awareness of the risks associated with gambling, but the extent to which these interventions can alter behaviour and therefore mitigate harm is yet to be ascertained.

In several countries, policy documents increasingly propose public health strategies to reduce harms at the national and local level,

with calls to regulate stakes and prizes, improve affordability checks, and provide better support to gamblers. Still, it is not clear how best to reduce the wider impact of gambling-related harms. We did a mapping review of review-level evidence to identify, appraise, and synthesise existing evidence for interventions that aim to reduce gambling-related harms, and to identify gaps in the evidence base.

The objective of the initial phase of our work was to map out and broadly describe the published systematic-review literature on interventions to address or prevent gambling-related harms. We included only systematic review-level evidence, but we applied broad criteria to include all forms of gambling and all populations (both studies that considered participants with an increased risk of gambling-related harms and studies that looked at the population as a whole). Although not typical of a mapping review, we carried out extractions at the level of full papers to allow us to generate a typology of the interventions done. The protocol of our mapping review is available online.

Search strategy and selection criteria

We searched the MEDLINE, Embase, Web of Science (Science Citation Index and Social Science Citation Index), Applied Social Sciences Index and Abstracts, PsycINFO, and Social Policy and Practice databases. The search strategy combined various terms relating to gambling and included both subject (Medical Subject Headings [MeSH]) and free-text searches ( appendix). We applied methodological search filters for systematic review-level evidence and scrutinised the reference lists of included studies. We limited results to reviews published since 2012-the date of the first comprehensive international review of gambling-related harms

-and to reviews published in English. For full details of the search terms used, see the appendix.

Search results were downloaded with EndNote, screened by LB (with 20% of results checked by SB), and coded with the keyword function. Papers that potentially met the inclusion criteria were coded and retrieved as full paper articles. For papers for which the title and abstract did not give a clear indication of whether the paper should be considered or not, we took an inclusive approach by examining the full paper.

Papers, to be included in our analysis, were required to address the whole population, identified gamblers (including self-defined), or specific populations at risk (eg, children and young people). The papers were also required to use any intervention to prevent or address gambling-related harms, with any or no comparison, and measure any outcome related to the prevention or treatment of gambling-related harms.

Data analysis

For studies judged to be potentially relevant, we obtained full papers and extracted and tabulated data on author, year, review design, setting, target population, intervention, inclusion criteria and search date, outcomes assessed, findings, conclusions, limitations, and notes. We synthesised the findings narratively and developed a typology of interventions. We drew on a systems approach adopted for the project overall to ensure that the mapping review considered evidence at all levels in systems connecting gambling activity to gambling-related harms. This approach meant we could identify where there were specific gaps in the availability of evidence. As is common for a mapping review,

we did not do a quality appraisal but we did record the type of study design.

A public advisory group consisting of eight individuals from across the UK with experience of gambling-related harms themselves, or through family or friends, provided advisory input via teleconference throughout the process. Their input highlighted the changing nature of people affected by addiction, emphasising the need to describe gambling as an addiction, and the lifelong struggles to avoid relapse. The group ensured that we considered wider population views on gambling-related harms, rather than just the views of the authors of included studies. We also sought participation from a broad range of stakeholders via a webinar, in which we discussed the initial findings from the mapping review. In total, 19 participants representing a range of practice, charity, and academic stakeholders from the UK attended the webinar and provided input regarding the implications of the evidence we had identified and gaps in our understanding.

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Identifying effective policy interventions to prevent gambling-related harm.

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Publication History

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DOI: https://doi.org/10.1016/S2468-2667(20)30230-9

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Our searches generated 1080 unique records. Of these records, 43 citations were retrieved as potentially relevant full papers. We excluded 13 from these 43 citations, mostly because the methodology was not systematic or the review did not consider intervention studies ( appendix).

Of the 30 papers that met the criteria for our Review, search end dates varied between 2011 (n=2) and 2018 (n=1), with half of all searches done between 2015 and 2017 (n=16). Three papers did not state their search dates. Publication dates ranged from 2012 to 2019 (with eight reviews published in 2018-19).

To synthesise the results of the identified systematic reviews, we developed a typology of interventions in terms of the study target population and the type of intervention. A draft list of interventions was taken from the work done to inform the Review protocol. Consideration was given to how well the reported interventions fitted the model and whether any gaps were notable.

The reviews were divided into those reporting on universal preventive interventions for the whole population and those evaluating selective interventions for individuals at high risk of harms. The whole-population preventive interventions included interventions to reduce the demand for gambling (demand reduction; n=3) and interventions to restrict opportunities to gamble (interventions restricting gambling activity; n=4). Targeted interventions for individuals at increased risk of gambling-related harms included therapeutic interventions (n=12), self-help or mutual-support interventions (n=4), and pharmacological interventions (n=5). We also included studies comparing different interventions (n=2).

Two further potential types of intervention we had expected to find were not represented in the systematic review-level evidence. First, interventions to screen, identify, and support individuals at risk of gambling-related harms (whole population). Second, interventions to support ongoing recovery and prevent relapse for gamblers at risk of harms. The intervention typology is outlined in the figure, with study details summarised in the table.

Table Systematic review-level evidence of interventions to reduce the burden of gambling-related harms

CBT=cognitive behavioural therapy. CINAHL=Cumulative Index to Nursing and Allied Health Literature. DSM=Diagnostic and Statistical Manual of Mental Disorders. ICD=International Classification of Diseases. PFI=personalised feedback intervention. RCT=randomised controlled trial.

Whole-population preventive interventions

Demand reduction

The interventions to reduce demand identified by our searches were limited to interventions delivered to children and young people. Three reviews reporting school-based education programmes were identified., ,

Keen and colleagues identified 19 studies of school-based education programmes for gambling. Programmes ranged from 20 to 500 min in length and typically consisted of videos viewed by whole classes. Nine studies measured outcomes related to gambling behaviour, of which five showed positive effects. Follow-up for most studies was short, and definitions of gambling-related harm and measures of gambling behaviour varied between studies. Ladouceur and colleagues reviewed both school-based programmes for the prevention of gambling-related harms, and gambling and related skills workshops to prevent gambling-related harms for youths (aged 9-20 years). The authors reported that programmes and workshops were both effective in reducing misconceptions and increasing knowledge about gambling in the short term, but a scarcity of long-term follow-up was noted. Kourgiantakis and colleagues aimed to identify programmes for the prevention of gambling-related harms that targeted children of gamblers. However, the 16 studies that they identified were all universal interventions and did not target their population of interest. Kourgiantakis and colleagues also reported a scarcity of long-term follow-up (no more than 3 months in most cases).

Review-level evidence on demand reduction interventions therefore, although sparse, suggests probable benefits of better gambling knowledge and attitudes of young people in the short term. However, little evidence regarding longer-term benefit exists. Establishing whether interventions are able to prevent the development of gambling-related harms in youths remains difficult.

Supply reduction

We identified four systematic reviews of interventions that aimed to facilitate gamblers themselves to restrict their gambling activity. Ginley and colleagues reviewed on-screen and poster warning messages related to gambling (limit-setting messages, educational animations, cash-expended displays, and personalised feedback) in both laboratory-based and so-called naturalistic studies (n=31). The review indicated that static signs have poor efficacy, but that pop-up messages can potentially reduce harm, particularly high-threat messages endorsed by medical or government agencies. Ladouceur and colleagues reviewed pre-commitment systems for electronic gaming machines. The studies (n=17) found variable adherence to time limits. Importantly, these studies failed to control for concurrent gambling outside the trial venues. McMahon and colleagues did a review of reviews on prevention and harm-reduction programmes for gambling in adults and youths, with and without a diagnosed gambling-related condition. They identified ten systematic reviews that met their inclusion criteria (n=55 studies). They reported some support for smoking bans, limit-setting messages, self-exclusion, prohibition of large notes, maximum bets, removal of cash machines, machine messages, and personalised feedback interventions but stated that the evidence overall was poor. Tanner and colleagues evaluated industry and environment-based strategies for the prevention of gambling-related harms (n=27 studies). They found mixed effects for mandatory limit-setting, smaller notes, on-screen clocks or counters, and smoking bans, but generally positive effects for removal of cash machines. As with the other reviews, the authors reported that studies were of poor quality, and there was a reliance on self-reported measures.

Up-to-date review-level evidence exists, therefore, for gambling interventions that encourage individual gamblers to restrict their own gambling, with on-screen pop-up messages appearing to be the most promising approach identified, particularly high-threat messages endorsed by medical or government agencies. However, no reviews were found that considered adherence to or regulation of enforcement interventions by these agencies. Little evidence to support industry supply-reduction initiatives was found.

Targeted interventions for individuals at increased risk of harm

Therapeutic interventions

12 reviews considered different types of therapeutic interventions for gamblers at risk of harm, including cognitive and behavioural therapies, motivational interviewing, psychological therapies in general, brief psychological interventions, self-help and mutual-support interventions, and internet-based therapies.

Challet-Bouju and colleagues

considered cognitive remediation interventions to reduce gambling-related harms but only identified one study. Similarly, Luquiens and colleagues reviewed cognitive training interventions but did not find any studies. Chrétien and colleagues reviewed cognitive restructuring interventions, a type of cognitive behavioural therapy (CBT), and identified 39 studies, but their review aimed to describe how the interventions were implemented with gamblers rather than evaluate effectiveness. Tolchard

reviewed studies of CBT or behavioural approaches, or both, including exposure therapy and cognitive restructuring. He suggested that both cognitive and behavioural approaches can be effective in reducing gambling-related harms. However, despite the use of systematic searching and inclusion criteria, this paper provides no clear indication of the volume of evidence considered. In a further study, Merkouris and colleagues reviewed all psychological treatments for adults seeking treatment for a gambling disorder and identified 50 papers reporting 33 studies. They reported that higher numbers of treatment sessions attended was associated with better gambling behaviour outcomes, and a range of socioeconomic factors also predicted treatment outcomes.

Petry and colleagues reviewed any psychological intervention for gambling (clinically or self-diagnosed). They included 21 trials and suggested that there is evidence regarding benefit from CBT alone or in combination with motivational interviewing but not from motivational interviewing alone. The authors also highlighted the scarcity of long-term follow-up. Cowlishaw and colleagues

also considered psychological therapies, including CBT, motivational interviewing, and integrative therapy. Their review identified 14 studies, of which 11 suggested that, at 3 months after treatment, CBT showed beneficial effects on gambling symptom severity and financial loss; however, longer-term benefits were unclear. Yakovenko and colleagues reviewed motivational-interviewing interventions (mostly one face-to-face session) in adult so-called disordered gamblers and reported a significant reduction in gambling frequency per month at 6-month follow-up (mean difference −1·22 days per month; 95% CI −2·06 to −0·38; p<0·05), and also at 9-month to 12-month follow-up (−1·12 days per month; 95% CI −2·16 to −0·07; p<0·05). However, they found no significant reduction in gambling expenditure at 6 months (p=0·07) or 9-12 months (p=0·15).

Two reviews considered brief psychological interventions for gambling-related harms. Peters and colleagues found that, in brief interventions of one session, the strongest predictor of short-term positive effect was the inclusion of an educational element, followed by motivational interviewing (n=11 studies). By contrast, Quilty and colleagues

defined brief interventions as interventions that last no more than three sessions and found evidence of a small but significant reduction in gambling behaviour in the short term.

The final two reviews in the group examining targeted treatments evaluated the evidence for internet-based therapies for gambling-related harms. Chebli and colleagues considered interventions that combined online therapeutic interventions with clinical assistance (via real-time chat or follow-up email) for adults seeking treatment. Only four of 16 studies considered pathological gambling. All studies evaluated CBT-based interventions and reported that favourable changes in gambling behaviours were sustained up to 3 years after intervention. van der Maas and colleagues reviewed internet-based interventions for gambling. Of 27 studies, most reported positive gambling outcomes, although only five of seven randomised controlled trials did so, and high rates of attrition were reported in some studies.

A considerable number of reviews of therapeutic interventions for gambling have been done in recent years. Despite this number, the evidence only indicates positive outcomes in the short term, with little evidence to support longer term effects or to favour one therapeutic intervention or mode of delivery over another.

Studies comparing targeted treatments

Goslar and colleagues compared face-to-face with self-guided therapy. 27 studies, mostly on electronic gambling, indicated higher effect sizes for face-to-face treatments in reducing gambling behaviour (frequency and financial loss) at 3 months than effect sizes for self-guided therapy. The intensity of treatment moderated the effect but the type of intervention did not. Sample sizes were small, and studies varied in terms of participant gambling severity. Rodda and colleagues

identified 46 studies of 35 psychological and self-help interventions. However, they did a content analysis of the type of change technique used in the interventions and did not consider effectiveness as an outcome measure. Therefore, there is little evidence available to compare one type of targeted intervention with another for reducing gambling behaviours.

Self-help and mutual-support interventions

Four reviews evaluated interventions that can be characterised as taking a self-help or mutual-support approach to managing gambling-related harms. Drawson and colleagues considered self-help interventions that aimed to reduce gambling behaviours through protective behavioural strategies such as self-exclusion, time and monetary limits, and cashless cards (instigated by the individual, not the service provider). Although they identified 33 studies, they reported that evidence was limited by low study quality. Self-exclusion was mostly endorsed by gamblers, but many returned to gambling after the exclusion period, and self-exclusion was not enforced by the casinos. Nevertheless, gambling frequency, duration, expense, debt, and urge were reduced up to 12 months after the intervention. Marchica and Derevensky

considered personal feedback interventions for gambling. Six studies, including three with university students, reported some reduction in a range of gambling behaviour outcomes and change in perceived norms around gambling behaviours. Schuler and colleagues reviewed Gamblers Anonymous meetings as a treatment for gambling behaviours. 17 studies in 25 publications (including four randomised controlled trials) showed a reduction in time and money spent on gambling. However, the review found that Gamblers Anonymous coupled with stress management was more effective than Gamblers Anonymous alone. The authors noted that attending meetings (rather than participating online) was important in achieving optimal outcomes. The review concluded that motivational interviewing and CBT combined were more effective than Gamblers Anonymous. Shonin and colleagues reviewed interventions derived from Buddhist philosophies or meditation techniques. The four included studies (cross-sectional and case studies) focused on mindfulness meditation with reported reductions in gambling severity, thought suppression, anxiety, and distress.

Drawing any clear conclusions from the review-level evidence for self-help interventions is difficult because of the diversity of interventions and a focus on fairly short-term self-reported behaviour change rather than long-term outcomes or direct measures of harm.

Pharmacological interventions

Five papers compared outcomes of pharmacological treatments for medically diagnosed gambling addiction and gambling-related harms (the evidence mostly came from randomised controlled trials). The drugs under consideration included opioid antagonists, glutamatergic agents, antidepressants, antipsychotics, mood stabilisers, and topiramate (an anticonvulsant).

Bartley and Bloch

compared opioid antagonists with placebo, identifying small benefits in 14 studies. Non-significant benefits were reported for antidepressants, antipsychotics, and topiramate versus placebo. However, the authors noted that early opioid trials were flawed because they did not use intention-to-treat analyses; therefore, the results might be skewed. Lupi and colleagues

identified 75 papers with conflicting findings for antidepressants, opioid antagonists, and mood stabilisers, and concluded that pharmacological interventions are promising for the treatment of gambling. More recently, Goslar and colleagues identified 39 studies and reported pre-post reduction in global gambling severity, frequency, and financial loss but did not find an advantage for any one type of pharmacological treatment over another. They note a small, non-significant advantage for combining a therapeutic treatment with a pharmacological intervention. Grant and colleagues reviewed 18 randomised controlled trials and suggested that opioid antagonists and glutamatergic agents might be the most promising treatments. However, the studies were small and the review method was not robust. In the fifth review in this group, Victorri-Vigneau and colleagues reviewed treatment with the opioid antagonists naltrexone and nalmefene. They identified 34 articles including seven randomised controlled trials, of which four showed positive effects. The authors hypothesised that pharmacological treatment is acting on underlying susceptibilities (eg, alcohol use disorder) as opposed to the gambling behaviour itself.

Therefore, as with the previous types of interventions, there is no conclusive message to support or refute the effectiveness of pharmacological interventions to reduce harm related to gambling behaviour. It is also not possible from the evidence identified to confidently recommend one drug treatment over another.

Our mapping review of interventions to address or prevent gambling-related harms identified systematic reviews evaluating whole-population preventive interventions and targeted interventions for individuals at high risk of gambling-related harms. Gambling-related harms are a fairly new concept with most of the literature focusing on so-called problem gamblers. This concept implies that interventions to address gambling-related harms should focus on changing the behaviour of individuals rather than on addressing the underlying causes of harmful behaviour that are related to gambling policies or provision. Moreover, gambling is different to other harmful behaviours, such as tobacco and alcohol consumption, for which a much more direct relationship has been established between the behaviour and risk of experiencing harm. Although studies of interventions to address so-called problem gambling or target problem gamblers can inform progress in preventing and treating gambling-related harms, it is important to acknowledge the limitations of these terms in addressing gambling-related harms at a societal or population level.

Although there have been some recent reviews, evidence from the primary literature remains sparse and weak, and review authors struggled to make conclusive statements about the evidence they examined, in terms of clear support for any specific types of intervention or for relative superiority of particular interventions or approaches over others. In addition to the weak study designs, the mapping-review method itself is restricted in scope in comparison with a complete systematic review

A typology of reviews: an analysis of 14 review types and associated methodologies.

and, as a result, findings should be treated with caution. However, given the need to advance gambling as a public health priority and the existence of a volume of relevant review-level evidence, this type of review remains an efficient way to consider and synthesise the current evidence base.

Review-level evidence was identified for gambling interventions that can reduce opportunities for potentially harmful gambling and for interventions that can reduce demand through information provision or educational programmes. However, the scope of interventions is restricted and the quality of evidence for reported effectiveness is very poor. Two clear gaps were identified in the review-level evidence. Firstly, screening interventions to identify individuals at risk of gambling-related harms who would benefit from brief interventions or referral to specialist treatment services. Secondly, evidence for on-going support after treatment for gambling-related harms. With evidence to suggest that well over half of all incident problem-gambling cases are previous problem gamblers who are relapsing,

this absence of support is an important omission. Further reviews of the primary study evidence for these two intervention approaches could clarify the current evidence base.

A policy report

has highlighted the complexity in addressing gambling-related harms but did not synthesise the evidence for intervention effectiveness. The authors emphasise the need for multifaceted and systemic interventions, including restrictions on advertising and marketing, changes to the structure of the industry and regulatory frameworks, and the tacking of industrial influence on research. These interventions would be needed to support the public health approaches considered in this Review.

Previous experience suggests that the gambling industry will strongly resist and argue against proposals to introduce interventions that might regulate or restrict their commercial activities. Common arguments from commercial interests include the suggestion that the complexity of the relationship between gambling activity and associated harms and the scarcity of robust evidence of effectiveness are rationales for delaying policy interventions until better evidence is available.

The public health responsibility deal: using a systems-level analysis to understand the lack of impact on alcohol, food, physical activity, and workplace health sub-systems.

The systems approach adopted for the project overall ensured that the mapping review considered evidence at all levels and all points in the systems connecting gambling activity to gambling-related harms. This approach meant we could identify where there were specific gaps in the evidence. It is, therefore, imperative to ensure that a scarcity of evidence is not used as a justification for inaction in addressing the growing burden of gambling-related harms. Instead, although action still needs to be based on the best available evidence, implementation needs to be accompanied by a comprehensive evaluation of both the intended and unintended consequences. This approach will, in time, allow the current deficiencies in the evidence base to be systematically addressed.

We declare no competing interests.

# data[].attributes.attachment_link.title
Interventions to reduce the public health burden of gambling-related harms: a mapping review

# data[].attributes.attachment_link.description
Recognition is growing that gambling, although highly profitable for corporations and governments, is a source of serious and unevenly distributed harm. This recognition has led to demands for public health strategies at the local, national, and international levels.